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Aortic Stenosis Progression: Review and Meta-Analysis
Quick Takes
- This systematic review and meta-analysis found that the pooled annualized rates of aortic stenosis (AS) progression were peak velocity (PV) +0.19 m/s, mean gradient (MG) +4.10 mm Hg, peak gradient (PG) +7.86 mm Hg, aortic valve area (AVA) –0.08 cm2, and aortic valve calcium score (AVC) +158.5 AU.
- There was a statistically significant correlation between baseline AS severity and the rate of AS progression for PV, MG, and AVC; but not for PG or AVA.
- Insufficient data were available to reliably address whether sex is associated with the rate of AS progression.
Study Questions:
What are the rates of aortic stenosis (AS) progression, and do sex or the baseline severity of AS impact disease progression?
Methods:
Published literature was searched for prospective studies evaluating the progression of AS using echocardiography mean gradient (MG), peak velocity (PV), peak gradient (PG), or aortic valve area (AVA); or computed tomography aortic valve calcium score (AVC). Random-effects meta-analysis was performed to evaluate the rate of AS progression for each parameter stratified by baseline severity, and meta-regression was performed to determine the impact of baseline severity and of sex on AS progression rate.
Results:
A total of 24 studies including 5,450 patients (40% female) met inclusion criteria. The pooled annualized progression of MG was +4.10 mm Hg (95% confidence interval [CI], 2.80-5.41 mm Hg), AVA –0.08 cm2 (95% CI, –0.06 to –0.10 cm2), PV +0.19 m/s (95% CI, 0.13-0.24 m/s), PG +7.86 mm Hg (95% CI, 4.98-10.75 mm Hg), and AVC +158.5 arbitrary units (AU) (95% CI, 55.0-261.9 AU). Increasing baseline severity of AS was predictive of higher rates of progression for MG (p < 0.001), PV (p = 0.001), and AVC (p < 0.001), but not for AVA (p = 0.34) or PG (p = 0.21). Only four studies reported AS progression stratified by sex, with only PV and AVC having three studies to perform a meta-analysis. No difference between sex was observed for PV (p = 0.40) or AVC (p = 0.57), but the level of confidence was low.
Conclusions:
This study provides progression rates for hemodynamic and anatomic parameters of AS, and suggests that increasing hemodynamic and anatomic baseline severity is associated with faster AS progression. The authors note that more studies are needed to determine if sex affects AS progression.
Perspective:
There is substantial variability in the literature on the rate of AS progression, with the availability of mostly retrospective studies that involve select patient cohorts and that use variable hemodynamic and anatomic measures of disease severity. In that setting, this study provides valuable data on the average rates of echocardiography-based hemodynamic progression of AS. The derived annual rates of increase in PV (0.18 m/s/y) and MG (+4.3 mm Hg/y) and the decrease in AVA (–0.08 cm2/y) for patients with moderate AS are somewhat lower than those cited in the 2020 ACC/AHA guideline for the management of patients with heart valve disease (respectively +0.3 m/s/y, +7 mm Hg/y, and –0.1 cm2/y); as is the upper 95% CI for PV progression (0.23 m/s/y, compared to ‘rapid progression’ defined as 0.3 m/s/y).
It is curious in this study that baseline AS severity was associated with the rate of progression for (along with MG and AVC) PV but not PG (echocardiographically derived from PV) or AVA. Fewer studies reporting PG might have contributed to the absence of a statistically significant correlation for that variable, and known methodological challenges could have contributed to the absence of a statistically significant correlation for echo/Doppler AVA. Although this study highlights the substantial variability between studies in estimates for the rate of AS progression, the data nonetheless could prove useful for timing follow-up intervals among asymptomatic patients with variable degrees of AS and variable amounts of AVC.
Clinical Topics: Noninvasive Imaging, Valvular Heart Disease, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging
Keywords: Aortic Valve Stenosis, Diagnostic Imaging, Disease Progression, Echocardiography, Heart Valve Diseases, Hemodynamics, Patient Acuity, Sex Factors, Tomography, Emission-Computed
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